This policy describes a variety of procedures addressing abnormalities of the head and neck. Cosmetic, reconstructive and medically necessary uses of these techniques will be addressed.
Please see the following for additional information:

• ANC.00007 Cosmetic & Reconstructive Services: Skin Related
• SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery
• MED.00054 Treatment for Obstructive Sleep Apnea in Adults
• CG-SURG-27 Gender Reassignment Surgery

Medically Necessary:  In this policy, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment.  Some situations where various procedures are considered medically necessary are described below.

Reconstructive: In this policy, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.  Some situations where various procedures are considered reconstructive are described below.

Cosmetic: In this policy, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance. Some situations where various procedures are considered cosmetic are described below.

1. Facial plastic surgery: (including, but not limited to, mentoplasty with or without implant, submental lipectomy, genioplasty)
   
   

   Facial plastic surgery is considered medically necessary when required to correct a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment.   Examples of physical functional impairment include procedures required to allow for speech, nutrition, control of secretions, protection of the airway, or corneal protection.
   
   Facial plastic surgery is considered reconstructive when used for restoration of appearance after an accidental injury or the medically necessary treatment of a disease. (Note: the initial restoration may be completed in stages)
   
   Facial plastic surgery is considered cosmetic/not medically necessary when done for familial jaw or chin deformities, or weak chin, or to remove excess fat or skin from under the chin.
   
   Note:
   Mandibular and maxillary orthognathic surgery is addressed in SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery. Orthognathic surgery for obstructive sleep apnea is addressed in  MED.00054 Treatment for Obstructive Sleep Apnea in Adults.
   

2. Otoplasty
   

   Otoplasty is considered medically necessary when performed for a surgically correctable congenital malformation, trauma, surgery, infection, or other process that is causing hearing loss. [Audiogram must demonstrate a loss of at least 15 decibels in the affected ear(s).] This procedure is also considered medically necessary in the setting of such a hearing loss if the surgery is intended to facilitate the use of a hearing aid. In addition, for cases to be considered medically necessary the procedure should be reasonably expected to improve the physical functional impairment.
   
   Otoplasty is considered reconstructive when performed to restore a significantly abnormal external ear or auditory canal related to trauma, tumor, surgery, infection, or congenital malformation. Repair of ear lobes only is not considered reconstructive.
   
   Otoplasty is considered reconstructive in the treatment of congenital absence of the external ear.
   
   Otoplasty is considered cosmetic/not medically necessary when performed for clefts or other consequences of ear piercing, or protruding ears.
   
   Otoplasty for any other indication is considered cosmetic/not medically necessary.
   

3. Rhinophyma
   
   Excision or shaving of the rhinophyma is considered medically necessary when medical record documentation includes evidence of bleeding or infection AND the procedure can be reasonably expected to improve the physical functional impairment of bleeding or infection.
   
   Excision or shaving of the rhinophyma is considered cosmetic/not medically necessary without documentation of medical necessity as defined above.
   
   Note:
   Acne Rosacea is addressed in ANC.00007 Cosmetic and Reconstructive Services: Skin Related.
   
   
4. Rhinoplasty
   
   Rhinoplasty is considered medically necessary when medical record documentation includes evidence of the failure of conservative medical therapy for severe airway obstruction from deformities due to disease, structural abnormality, or previous therapeutic process that will not respond to septoplasty alone AND the procedure can be reasonably expected to improve the physical functional impairment. (Note: Only the initial restorative repair is medically necessary, unless the procedure is normally done in stages with healing periods, then all stages are medically necessary.)
   
   Rhinoplasty is considered reconstructive if there is documented evidence (i.e., x-rays) of nasal fracture. This policy is not to be applied to surgery to correct valvular collapse, congenital anomaly (e.g., cleft lip nasal deformity), or nasal reconstruction following trauma or disease.
   
   Rhinoplasty is considered cosmetic/not medically necessary without documentation of medical necessity as defined above. Specifically, rhinoplasty to modify the shape or size of the nose is considered cosmetic/not medically necessary.
   
   
5. Rhytidectomy (Face lift)
   
   Rhytidectomy is considered reconstructive when performed for the treatment of significant burns or other significant major facial trauma.
   
   Rhytidectomy is considered cosmetic/not medically necessary for all other indications, such as when performed to remove wrinkles, excess skin or to tighten facial muscles.
   
   
6. Cranial Nerve Procedures
   
   Transfers, anastomosis of other procedures of the Facial nerve or other cranial nerves or their branches are considered medically necessary when required to correct a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment. Examples of physical functional impairment include, but are not limited to, procedures required to allow for speech, nutrition, control of secretions, protection of the airway, or corneal protection.
   
   Transfer, anastomosis or other procedures of the Facial nerve, or other cranial nerves or branches are considered reconstructive when performed for the treatment of congenital or acquired facial palsy which have resulted in a significantly altered appearance.
   
   
7. Ear or body piercing
   
   Ear or body piercing is considered cosmetic/not medically necessary when done for any reason.
   
   
8. Frown Lines
   
   Removal of frown lines is considered cosmetic/not medically necessary when done for the excision or correction of glabella frown lines or forehead lift (cosmetic foreheadplasty).
   
   
9. Neck tuck
   
   

   Neck tucks are considered cosmetic/not medically necessary when done for any reason.
   

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat musculoskeletal abnormalities is often based on a determination of whether the abnormality is considered medically necessary, reconstructive or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant physical functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service “returns the patient to whole” as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive definitions, include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy. 

Ear and body piercing is done for cosmetic or aesthetic reasons. Piercing the ears, nose, lip, or any other body part has no acceptable medical use and therefore is not considered medically necessary.

Facial plastic surgery is a general term for any surgery that proposes to alter the appearance of the face. For the purposes of this policy the term specifically relates to surgery that is designed to alter the appearance of the lower face including the upper and lower jaw, and chin. Surgery for these portions of the face may be considered cosmetic, or may be indicated in instances where severe abnormalities result in functional impairments that affect the ability to eat, swallow, or breathe. These procedures may also be reasonable to correct or restore appearance following traumatic injuries or surgery to treat a medical or surgical condition that result in anatomical changes.

Surgery for frown lines is intended to remove wrinkles that result from the aging process. A “neck tuck” is a surgical procedure to remove excess skin and fat from the neck area under the chin. This area may also be referred to as a double chin. Neither of these surgeries has any medical purpose. Their usefulness is solely cosmetic.

Osteotomy & Osteoplasty are surgical procedures which involve the opening of a bone (osteotomy), or to reconfigure a bone (osteoplasty). Such procedures are required when the alignment of a bony structure is misaligned to such a degree that functional impairment results. These types of surgeries are usually complex and may involve several procedures or steps to accomplish the desired result.

Otoplasty refers to surgical procedures that are intended to reshape the structure of the outer ear that is misshapen or injured, or to construct an ear that may have been absent at birth or due to trauma. Such surgery may be considered cosmetic when there is no functional physical impairment or trauma involved. In instances where the ear is misshapen enough to interfere with normal hearing, is absent at birth, or has been deformed due to disease or trauma, restoring a normal appearance to external ear is considered medically reasonable.

Rhinophyma is a condition where the nose becomes enlarged, red and knobby. The cause is unknown but has been associated with long standing rosacea, a chronic skin rash that is characterized by a reddening of the skin on the face. This condition almost exclusively afflicts white men over 40 years of age, although some cases have been reported in women and younger patients. Because this condition results in many pits and fissures in the skin, bleeding and infection may result. When such circumstances develop, medical treatment is indicated. Otherwise, treatment of rhinophyma is considered cosmetic in nature.

Rhinoplasty, also known as a “nose job”, is a surgical procedure intended to alter the shape of the nose. This procedure is primarily intended to alter the shape of air pathways to improve the passage of air while breathing, or to correct structural damage due to disease or trauma. In many cases the shape of the inside of the nose, mainly the septum which separates the nostrils, prevents adequate air passage, impeding proper breathing. In other cases, the shape of the nose may become deformed due to disease or trauma resulting in blocked nasal passages. When such circumstances exist rhinoplasty is indicated. Rhinoplasty to alter the external appearance of the nose is very common. Such use of rhinoplasty has no medical benefits and is not considered medically necessary.

Finally, a rhytidectomy, or “face lift” is a surgical procedure where excess skin is removed from the face and the muscles of the face are tightened to correct a facial abnormality due to burns or facial palsy resulting in a droopy appearance. Additionally, face lifts are used to create a more youthful appearance in individuals concerned with changes due to the aging process. In patients with facial injuries due to burns or lax facial muscles due to palsy the use of rhytidectomy may allow the restoration of a normal appearance. For patients with no functional impairments or disease or injury-related facial changes, rhytidectomy is considered a cosmetic procedure.

Genioplasty: a surgical procedure intended to reshape the chin

Keloids: a condition where a scar becomes raised above the plane of normal skin and has a hardened texture

Mandibular: pertaining to the lower jaw

Maxillary: pertaining to the upper jaw

Mentoplasty: a surgical procedure intended to alter the shape of the chin through the use of various implantable devices to make the chin more prominent

Neck tuck: a surgical procedure intended to correct the appearance of the neck

Osteotomy/Osteoplasty: surgical procedures which involve the opening of a bone (osteotomy), or to reconfigure a bone (osteoplasty)

Otoplasty: a surgical procedure to reshape or rebuild the ear

Palsy: a condition affecting the nerves resulting in the inability to move and relaxed, droopy muscles

Prognathism: a condition where the lower jaw extends beyond the upper jaw, also known as an under-bite

Rhinophyma: a condition where a person has a bulbous, enlarged, red nose and puffy cheeks; there may also be thick bumps on the lower half of the nose and the nearby cheek areas

Rhinoplasty: a surgical procedure intended to reshape the nose or repair a broken nose

Rhytidectomy: a surgical procedure intended to adjust the appearance of the face by removing excess skin and tightening the underlying muscles

Septoplasty: a surgical procedure intended to repair the nasal septum, a cartilage and bony structure that separates the two nostrils

Submental lipectomy: a surgical procedure intended to remove excess fat below the chin, commonly referred to as a double chin

The following codes for treatments and procedures applicable to this policy are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Facial Plastic Surgery 

Services may be Medically Necessary when criteria are met:

CPT

HCPCS

ICD-9 Procedure

ICD-9 Diagnosis

When services may be Reconstructive:

For procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Policy section as reconstructive.

When services are Cosmetic/Not Medically Necessary:

For procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Otoplasty

When services may be Medically Necessary when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services may be Reconstructive:

For procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Policy section as reconstructive.

When services are Cosmetic/Not Medically Necessary:

For procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Services may be Reconstructive when criteria are met: 

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Cosmetic/Not Medically Necessary:
For procedure codes listed above, when criteria are not met for reconstructive services, or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Rhinophyma Surgery

When services may be Medically Necessary when criteria are met:

CPT

ICD-9 Diagnosis

When services are Cosmetic/Not Medically Necessary:

For procedure code listed above, when criteria are not met for medically necessary services, or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Rhinoplasty

When services may be Medically Necessary when criteria are met: 

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services may be Reconstructive:

For procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Policy section as reconstructive.

When services are Cosmetic/Not Medically Necessary:

For procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Rhytidectomy (face lift)

When services may be Reconstructive when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Cosmetic/not medically necessary:

For procedure codes listed above, when criteria are not met for reconstructive services, for all other diagnoses, or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Cranial Nerve Procedures

When services may be Medically Necessary when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services may be Reconstructive:
For procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Policy section as reconstructive.

When services are Cosmetic/Not Medically Necessary:
For procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Other

When services are Cosmetic/Not Medically Necessary:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

Peer Reviewed Publications:

1. Hoeyberghs JL. Fortnightly review: cosmetic surgery. BMJ. 1999; 318(7182):512-516.
2. Vuyk HD. A review of practical guidelines for the correction of deviated, asymmetric nose. Rhinology. 2000; 38(2):72-78.
3. Yugueros P, Friedland JA. Otoplasty: the experience of 100 consecutive patients. Plast Reconstr Surg. 2001; 108(4):1045-1053.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Plastic Surgeons. Recommended criteria for third-party payer coverage: Nasal Surgery. July 2006. Available at:  http://www.plasticsurgery.org/medical_professionals/Policy_Statements/ loader.cfm?url=/commonspot/security/getfile.cfm&PageID=18269. Accessed on September 22, 2006.
2. American Society of Plastic Surgeons: Recommended insurance coverage criteria for third-party payers: Ear deformity: Prominent ears. December 2005. Available at:  http://www.plasticsurgery.org/medical_professionals/Policy_Statements/ loader.cfm?url=/commonspot/security/getfile.cfm&PageID=17675. Accessed on September 22, 2006.
3. American Society of Plastic Surgeons. Position paper: Ear deformity: Prominent ears. January 1998. Available at:  http://www.plasticsurgery.org/medical_professionals/publications /loader.cfm?url=/commonspot/security/getfile.cfm&PageID=7125. Accessed on September 22, 2006.
4. American Society of Plastic Surgeons and the American Academy of Pediatrics. Section on Plastic Surgery. Position Statement: Healthcare for the reconstruction of abnormal appearance. June 1998. Available at:  http://www.plasticsurgery.org/medical_professionals/publications/ loader.cfm?url=/commonspot/security/getfile.cfm&PageID=7132. Accessed on September 22, 2006.
5. Centers for Medicare and Medicaid Services. National Coverage Determination for Plastic Surgery to Correct Moon Face. NCD #140.4. Effective May 1,1989. Available at:  http://www.cms.hhs.gov. Accessed on September 25, 2006.
6. Institute for Clinical Systems Improvement (ICSI). Rhinitis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2003 May. 34 p. Available at:  http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=158.  Accessed on September 25, 2006.

1. American Society for Aesthetic Plastic Surgery. Available at: http://surgery.org. Accessed on September 25, 2006.
2. American Academy of Facial and Reconstructive Plastic Surgery. Available at: http://www.facial-plastic-surgery.org. Accessed on September 25, 2006.
3. American Academy of Plastic Surgery. Available at: http://www.plasticsurgery.org.  Accessed on September 25, 2006. 

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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